Mysterious Knee Surgery Deaths?

nurs4kids · Nov 21, 2001

Being an old Central Supply girl, it's my guess that it's linked to the implanted device, since it's at more than one hospital. Ortho docs aren't finatical about doing blood cultures; was probably treating with broad spectrum abx, if any, ended up septic. C-diff will kill, even with ruptured bowel, if not treated promptly.

just my guess

P_RN, ADN, RN · Nov 21, 2001

Nothing new on the news reports?

My first reaction was also PE (The BLUE torpedo). They do use a tourniquet in knee operations, but "usually" PEs come from clots above the knee.....I assume the doctors kept a close eye on the tourniquet time.

Then I thought C diff.....but these were different doctors and different hospitals.....so did they all OVER antibiotic these patients?

Then I read about the (Baxter?) dialysis filters that were said to be contaminated during manufacture...and led to deaths....and the (Sulzer) total hip components that are said to fail due to manufacturing error....

Then I recalled many years ago that there was a BIG case of contamination of IV fluids.......Abbott I believe.

THEN I read that there were several deaths resulting from salmonella contaminated fresh TOMATOES and some were in Minnesota......

I wonder if we will EVER get the rest of the story?

BlueBear · Nov 22, 2001

I'm only getting bits and pieces of the story here in NJ but am very curious as to what is going on. I figure it has to be a specific individual contaminating patients. Keep us posted P RN. I would love to know the whole story!

WriteStuff · Nov 22, 2001

:rolleyes:

Subject line above was the front page headline in the Star Tribune today - the Twin Cities largest newspaper circulation.

Here are some "out-takes" from that article:

*****************************

Calls are flooding in from all around the country (to Atlanta CDC, and Minnesota Health Officials).....which has broadened the investigation significantly.

Statewide halt in elective knee operations has been in effect, possibly will be lifted by Monday next week.

Minnesota Dept. of Health has established a Hotline to handle calls, the number is: 612-676-5414

CDC in Atlanta can be reached at : 1-800-893-0485

This is a quote from Prof. Michael Osterholm, director of the Univ. of Minnesota Center for Infectious Disease Research and Policy: "state health officials may have uncovered a major national problem that was previously unrecognized."

State Epidemiologist, Dr. Harry Hull and his investigators "suspect that the three men died of a rare infection of the deadly bacteria Clostridium sordellii. The two older men who died had knee replacements, while the younger man (age 23), had a cartilage graft. They all experienced similar symptoms: severe stomach pain, a sudden drop in blood pressure and rapid death.

A quote: "At the moment, no one knows how all three men might have been infected with the same organism. Invesitgators are awaiting test results and are exploring various theories, including whether some surgical supplies or equipment was contaminated."

Similar cases have now come to light involving knee replacement surgeries in other parts of the country, although these occurred months ago, and have never been investigated: one was in Burnsville, MN, another in Austin, Texas, and calls continue to come in.

Another quote from this article: "Investigators are checking out reports that a Minnesota woman died following hip surgery and others have raised questions about cases involving shoulder and ankle surgeries. If they pan out, Hull said, the Health Department may expand the voluntary moratorium to include other types of orthopedic surgery, unless it can pinpoint the exact cause. The moratorium on knee surgery, he said, is simply 'a precaution while the investigation is continuing.'"

***********************

It was also announced on local stations today that investigators are taking DNA tissue samples of all victims for further investigation.

Thought you all might want to know what's being said in the news media here.

Curiously, it was also reported today by the local TV News media that "so far investigators are coming up with "zero" in terms of who, what, why, when, where in making any "connection" with the cases.

It suddenly reminds me of what we know about the beginning days of medicine and surgery, when death was a common occurrence after surgeries- because the simple act of handwashing was not recognized for the crucial importance that we know it is today.......how else would a fresh post-op wound in the "sterile" setting of a surgical suite become contaminated with such a nasty bacterium as C.diff? Who DID NOT adhere to the simple measures of handwashing and/or gloving where these patients were concerned??

Bonnie Creighton,RN

P_RN, ADN, RN · Nov 22, 2001

Handwashing...my first nursing paper when I went back to school was on Ignaz Semmelweis and childbed fever.....handwashing.... carries me back.

http://www.cdc.gov/od/oc/media/pressrel/r2k0306c.htm

I'm following this carefully. My hip gets any worse I might be thinking about one myself.

I'm still betting on supply contamination.

WriteStuff · Nov 22, 2001

P_RN, thanks for the link.........I just printed it out and will read it in the morning.........although it IS morning now......as in 1:00am.

But I want to read it when my "brain" is recharged.

Thanks for sharing it.......

And, I agree with you......it WILL be about gross contamination due to a breakdown in the all important steps so necessary to prevent it in the first place.

Bonnie Creighton,RN

P_RN, ADN, RN · Nov 23, 2001

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5046a3.htm

The CDC site finally has something on this. How about the local media?

Also in The Lancet there are articles about IV drug users who have died from the same bacterium.

mcl4 · Nov 23, 2001

Originally posted by jmspeach
I didn't mean it like it sounded, I know that they stopped the surgeires. Sorry if you took such offense to my post, but they have been saying the same thing over and over for a couple of days now, just diffrent wording.

I didn't take offense to your post, however, I disagree it has been kept quiet. They are saying the same thing over and over since there is no new information.

mcl4 · Nov 23, 2001

"

***********************

It was also announced on local stations today that investigators are taking DNA tissue samples of all victims for further investigation.

Thought you all might want to know what's being said in the news media here.

Curiously, it was also reported today by the local TV News media that "so far investigators are coming up with "zero" in terms of who, what, why, when, where in making any "connection" with the cases.

It suddenly reminds me of what we know about the beginning days of medicine and surgery, when death was a common occurrence after surgeries- because the simple act of handwashing was not recognized for the crucial importance that we know it is today.......how else would a fresh post-op wound in the "sterile" setting of a surgical suite become contaminated with such a nasty bacterium as C.diff? Who DID NOT adhere to the simple measures of handwashing and/or gloving where these patients were concerned??

Bonnie Creighton,RN [

Handwashing has not been ruled as the cause of complications from these knee procedures and surgical scrubs are not taken for granted in an OR. At the end of the investigation, they still have not come up with the answer why these men died within a short period of time of one an another from knee surgery. Please note only ONE patient's test came back positive for Clostridium sordelli.

Published Nov 22 2001

Saying their investigation has failed to demonstrate that knee surgery is unusually risky, Minnesota health officials gave hospitals the green light to resume the operations Monday after a weeklong moratorium.

Officials say they're still stumped as to why three apparently healthy men died last week after knee surgery at two central-Minnesota hospitals.

But so far, an intense investigation has turned up no new clues and no new cases that fit the pattern, Dr. Harry Hull, the state epidemiologist, said Wednesday.

"Unless new information comes to our attention between now and Sunday, we now believe it's safe to start offering this procedure again," said Hull, who is leading the investigative team.

Hundreds of knee operations were postponed throughout Minnesota after the Health Department on Sunday took the extraordinary step of calling for the moratorium. Officials suspected that a bacterial infection was to blame, and they wanted time to find out how the men may have been infected.

In spite of a national alert that prompted hundreds of calls about potential new cases, Hull said Wednesday that none was "clearly similar to the three deaths that prompted the moratorium."

Meanwhile, investigators have been unable to find a "smoking gun" tying even the three deaths together. Only one victim, Brian Lykins, 23, a college student in Willmar, tested positive for the bacterium, Clostridium sordelli; the others so far have tested negative. Investigations at the two hospitals, in Alexandria and St. Cloud, have turned up "no common thread," the Health Department said.

With the investigation stymied, Hull's team decided Wednesday to let the moratorium lapse, following a conference call with other investigators.

"The question of the hour is will it be safe to resume surgery on Monday?" Hull said. "People need to know now because patients need to be scheduled." Given the evidence, he said, "we've not demonstrated that surgery next week would be any more dangerous than surgery was a year ago."

He defended the decision to call for a halt in the operations.

"We have anticipated from the very beginning that we might come up with nothing at the end of the moratorium period," he said. "But we felt that we had to take this precautionary step on the presumption that there might be a bigger problem."

Earlier Wednesday, an investigator at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta said there were no plans to widen the moratorium to other states. "At this point we don't know that it's associated with any medication or any surgical instrument or procedure," said Dan Jernigan, an epidemiologist leading the CDC's role in the investigation. "There are always risks going into surgery, but at this point there does not appear to be an elevated risk." Nevertheless, the CDC posted a nationwide alert in its newsletter, Morbidity and Mortality Weekly Report, calling for reports of any similar cases dating back to Oct. 1.

In Minnesota, the moratorium has sparked little protest from doctors. "I think most of them are pretty sympathetic," said Dr. Scott McPherson, a Park Nicollet orthopedic surgeon and president of the Minnesota Orthopaedic Society. "People just want to do the right thing, and they know that those elective cases will be there later on."

Dr. Ed Szalapski, who specializes in knee surgery at Fairview Southdale Hospital in Edina, agreed. "None of us wants to proceed with our surgical schedules and have a patient die," he said. But, he added, "We can't stay in limbo forever. Sooner or later we'll all have to go back to work and take care of our patients."

Jernigan said the unusual cluster of deaths might turn out to be "just bad luck." But he defended the high state of alert. "If we've been overzealous," he said, "then that's just what we'll have to live with."

mcl4 · Nov 23, 2001

Originally posted by nurs4kids
Being an old Central Supply girl, it's my guess that it's linked to the implanted device, since it's at more than one hospital. Ortho docs aren't finatical about doing blood cultures; was probably treating with broad spectrum abx, if any, ended up septic. C-diff will kill, even with ruptured bowel, if not treated promptly.

just my guess

Total knees are on broad spectrum IV antibiotics post op. Osteomylitis is serious and the surgeons go out of their way to prevent this. These three patients were all discharged to home and died quickly after readmission. I'm sure blood cultures were done upon readmission, but they are not routinely done on patients who do not show signs/symptoms of infection post operatively. Also, results from blood cultures do take time to come back. I disagree with the statement that ortho docs do not order blood cultures. I've seen them ordered many times.

P_RN, ADN, RN · Nov 24, 2001

Having worked Ortho in a big teaching center, I've dealt with the "boney boys & girls" for nearly 30 years. As far as BC, in my experience some do, most don't order them. Post op fever is usually dealt with by vigorous pulmonary exercise, hardly ever with APAP.

Total knees are usually discharged on day 3 nowdays. A mosaicplasty or cultured cartelage transplant-Im not sure which- may only stay overnight. We had one Ortho who wanted his TKA patients discharged to the rehab center directly from PACU.

Total joints are always done in the laminar flow room for sterility.

They usually got 3 post op doses of ancef and that's all. They usually were anticoagulated at home with coumadin although one doc used Lovenox ($$$$$) for 6 weeks post op. He's also one of the big blood culture believers.

nurs4kids · Nov 24, 2001

Thank you, PRN.

I worked ortho for a year, think I may have done blood cultures a few times. Also, did I not say they don't ROUTINELY order BC's??? In no way did I intend to imply the ortho docs did something wrong. It's be pretty stupid to order bc's on every ortho case that runs a temp, since the temps ARE normally pulmonary. :rolleyes:

Ancef is what's normally used here too, X3 doses. I WAS not saying the docs were wrong. I figure it's manufacturer packaging or something.

I'll have my head back now, thank you Bonnie!